Provider Demographics
NPI:1437656444
Name:KIM, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 SAINT ANN DR
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-1194
Mailing Address - Country:US
Mailing Address - Phone:518-527-6781
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:267-964-0784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310460208000000X
PAMD478920208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics